How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations.

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Priorities for action on the social determinants of health: Empirical evidence on the strongest associations with life expectancy in 54 low-income countries, 1990-2012.

The WHO Commission on the Social Determinants of Health set out an impressive collection of policy proposals on the social determinants of health. However, a serious weakness for securing implementation is the difficulty for policymakers in identifying priorities for action. The objective of this study is to determine a small set of the most influential determinants using existing data and an empirical approach. 45 Indicators from the World Bank's World Development Indicators are selected to measure attainment for the determinants proposed by the Commission. Panel data models of life expectancy at birth for 54 low-income countries over the years 1990-2012 (1188 country-years) are estimated. Each determinant is subjected to a robustness test using Extreme Bound Analysis, to determine the stability of its estimated impact on life expectancy. For 20 robust and significant determinants the magnitude of association with life expectancy is determined. The largest average increases in life expectancy at 14.5 months per capita is associated with a one standard deviation reduction in HIV prevalence among children, followed by advances in gender equality at 9.4 months. Improvements in life expectancy between 6 and 9 months are associated with agricultural production, political stability, access to clean water and sanitation, good governance, and primary school enrolment. Improvements below 6 months are associated with increases in private health expenditure and overseas development assistance, and control of armed conflict and HIV prevalence among men. There is no evidence that national income, public spending on healthcare and education, secondary schooling, terms of international trade, employment, debt service and relief, out-of-pocket expenditures, agricultural ex- or imports, lifestock production, foreign investment, urbanization or environmental degradation are robustly associated with population health. Results provide support for the relevance of some proposed policies. The findings can inform priorities for future research and policy action on the social determinants of health.

Ethics and geographical equity in health care.

Important variations in access to health care and health outcomes are associated with geography, giving rise to profound ethical concerns. This paper discusses the consequences of such concerns for the allocation of health care finance to geographical regions. Specifically, it examines the ethical drivers underlying capitation systems, which have become the principal method of allocating health care finance to regions in most countries. Although most capitation systems are based on empirical models of health care expenditure, there is much debate about which needs factors to include in (or exclude from) such models. This concern with legitimate and illegitimate drivers of health care expenditure reflects the ethical concerns underlying the geographical distribution of health care finance.

Capitation and risk adjustment in health care financing: an international progress report.

In every system of health care, capitation payments have become the accepted tool used by health care purchasers in much of the developed world to determine prospective budgets. The policy prescription of capitation is perceived to address both equity objectives (of great importance in publicly funded systems of health care) and efficiency objectives (the dominant concern in competitive insurance markets). An examination of the current state of the art in 20 countries outside the United States in which health care capitation has been implemented confirms that capitation has assumed central importance within diverse systems of health care. In practice, however, the setting of capitation payments has been heavily constrained to date by poor data availability and unsatisfactory analytic methodology.

Equity in the allocation of health care resources.

This paper examines some of the issues that arise when seeking to tackle health inequalities in a context of limited health care resources. Increasingly, central agencies are using devolved budgets for health care providers as a central instrument of expenditure control. Equity objectives play an important role in the resource allocation methods used to determine such budgets. Yet, unless integrated into a proper system of risk management, the use of budgets can lead to serious inequity. The paper discusses the potential contributions of different disciplines to promoting equity within a health care budgetary regime.

Capitation and risk adjustment in health care.

Capitation and risk adjustment have become the chosen policy instruments to seek cost containment and equity of access for many developed health care systems. Increasingly, this entails the prospective setting of global budgets for the health care expenditures incurred by health care plans on behalf of their members. Methods of deriving such budgets are diverse and tailored to the specific circumstances of the health care system they seek to serve. This special issue presents a collection of papers devoted to issues surrounding the rationale, derivation, and implementation of capitation and risk adjustment methods of financing health care. These are discussed within the context of health care systems in eight countries, illustrating the range of interest in the topic. Undoubtedly, capitation and risk adjustment will become increasingly significant elements of virtually all systems of health care and we hope the collection of papers will help to stimulate further debate and research in this important and interesting area of health care financing.

Incorporating option values into the economic evaluation of health care technologies.

Despite uncertainty being intrinsic to economic evaluation of health care, existing techniques for handling uncertainty remain underdeveloped compared to the formal techniques commonly applied in the business sector. This paper develops an alternative approach to handling uncertainty in economic evaluation based on 'option-pricing' techniques. The presence of uncertainty and the degree of irreversibility of a decision make it clear that some flexibility in the timing of a decision is often a desirable characteristic with an economic value. We demonstrate how option-pricing techniques can be applied to the decision rules for economic evaluation in health care. The key determinants of an option value are the presence and type of uncertainty; the ability to defer a decision; and the irreversibility of the decision. The relative significance of each of these for a particular economic evaluation will depend on the particular characteristics of the technology under consideration.

Risk and the general practitioner budget holder.

For most individuals, the use made of health care in a given year is determined principally by unpredictable random incidents. Of course, some individuals have a predictably higher predisposition to illness than others. However, the general consensus is that only a fraction of individual variability in health care costs can be predicted. The purpose of this paper is to explore the implications of this inherent randomness for setting health care budgets for general practitioner purchasers of health care. The paper argues that variability in utilization in health care is very high: that no capitation formula can ever completely capture that variability, even for large populations: that the variability may give rise to certain dysfunctional consequences if not managed carefully; and that therefore careful attention should be given to the managerial arrangements associated with any devolution of health care budgets.

Principal-agent problems in health care systems: an international perspective.

A central feature of all health care systems is the flow of finances from the population, via a variety of agencies, to the providers of health care. Each transfer of funds within the system involves a principal-agent problem, in the sense that a principal is entrusting funds to an agent with the intention that some desired aspect of health care delivery can be secured. This paper examines within the context of a principal-agent model three key elements of the health care system: the raising of finance, the transfer of funds to hospitals, and spending by hospitals. At each of these stages there is a danger that the objectives of society for the health care system are lost. In order to illustrate the issues involved, five mature systems of health care are examined: Austria, Germany, the United Kingdom, the Netherlands and the United States of America. The paper concludes that three aspects of the flow of funds are crucial to securing adequate control: the means of controlling patient entry to hospitals; the mechanism for remunerating hospitals for additional patients; and the control of physicians by hospital management.

Patient classification in home health care: are we ready?

This longitudinal descriptive study retrospectively profiled the acutely ill patient in home health care and explored the utility of using patient record data in predicting agency resource use and patient outcome. The findings suggest that those variables traditionally relied on for reimbursement qualification and as components of patient-classification schemes may not be wholly adequate to explain resource use and patient outcome in the home health setting. Professional nursing judgment of the patient's prognosis was found to be the most sensitive variable predicting outcome. Selected diagnoses and self-care capacity of the patient were the major predictors of resource use. Suggestions are offered for further studies that may move public health nursing more quickly toward the development of consistent and accurate home health care case mix measures.

Asian Americans: growth, change, and diversity.

PIP: The 1980 US census counted 3.5 million Asian Americans, up from 1.4 million in 1970. Asian Americans made up just 1.5% of the total US population of 226.5 million as of April 1, 1980, but this was the 3rd largest racial or ethnic minority after blacks and Hispanics. Asians increased far more during the 1970s (141%) than blacks (17%) or Hispanics (39%). This Bulletin examines the characteristics of Asian Americans, how their numbers have grown, where they live, how different groups vary in age structure, childbearing, health, and longevity. It reports on the kinds of households Asian Americans form and how they fare with regard to education, occupation, and income. Asian Americans are now often perceived as the model minority. As a whole, they are better educated, occupy higher rungs on the occupational ladder, and earn more than the general US population and even white Americans. This Bulletin presents the 1st comprehensive look at many important facts about Asian Americans and how the groups differ. Special tabulations of data collected in the 1980 census are provided. The 1980 census data are the latest available to give a true picture at the national level of Asian Americans and the various groups among them. The Bulletin examines the current numbers of Asian Americans and how this population is defined. The major Asian American groups are Chinese (21%), Filipinos (20%), Japanese (15%), Vietnamese (21%), Koreans (11%), and Asian Indians (10%). Except for the latest-arrived Vietnamese, the fertility of the 6 groups is lower than the white average. The following areas are also discussed: mortality and health; families and households; education; Asian youth; employment; income and poverty; and future prospects.^ieng

Migration of women to cities: the Asian situation in comparative perspective.

PIP: Contrary to the popular notion that women migrate only as part of families, and therefore, the causes and consequences of their migration are those of their spouses' or families,' studies of migration in some Asian countries have reported indications of increasing numbers of young women joining the migrant flow to the cities. Many of the women go on their own to find employment in the service, manufacturing and informal sectors, as factory and assembly line workers, as in Southeast Asia. The Philippines has the highest level of female participation in rural-urban migration. However, there is no consistent selectivity of 1 sex over the other in the migration process within subregions, except perhaps in the South Asian countries such as India, Pakistan and Sri Lanka which show male selectivity in migration to the cities. In East Asia, women also form a majority among migrants to the cities in South Korea. Japan appears to have male dominant migrant streams, while the pattern in Taiwan and Malaysia seem to be in transition toward increasing female migration. Female migration appears to be associated with: 1) female participation in agriculture; 2) availability of job opportunities for women in the cities; and 3) sociocultural restrictions on the mobility of women. In keeping with this typology by Boserup (1970), the present study finds a positive correlation between employment opportunities for women in the cities and female migration, as in the case of Thailand, the Philippines, Malaysia and Taiwan. In Thailand and the Philippines, women face a flexible attitude toward their roles and few cultural restrictions on their movement, whereas, in Taiwan and Malaysia, benefits of development and monetary attractions have weakened previously strong traditional forces. Alternatively, where cultural and religious constraints on freedom of movement continue to exist for women, along with few economic opportunities, as in the South Asian countries, a relatively low level of female migration is observed. There is also much evidence that rural-urban migration of men as well as women is positively linked to schooling.^ieng

Utility of the routine left lateral view in gated blood pool studies.

One hundred twenty-four sequential gated blood pool studies were examined by four observers in order to determine the impact on overall interpretation created by the addition of a routine left lateral view to supplement the standard LAO and RAO projections. Of these 124 studies, 114 studies in 87 patients were considered technically adequate. Forty-one of the 114 studies revealed differences in the perception of apex motion in the LAO as compared with the left lateral view. In seven of these 41 cases, the overall diagnostic impression was altered by the left lateral view. A 15-minute increase in technician time at an incremental cost of $3.00 is attributed to the added view. Approximately 6% of overall diagnostic impressions were altered because of this additional routine view.